c


 
 
 ABDOMEN: Normal bowel sounds. Soft, nontender. No
Joseph R. Smith
1234567-8
4/5/2006
REASON FOR VISIT: Here to get a new primary care
physician.
HPI: Mr. Smith is a 56-year-old gentleman formally
followed at Carolina Premier who presents to obtain a
new primary care physician secondary to insurance
changes. He has a past medical history significant for a
myocardial infarction in 1994. His cholesterol has been
fine. Catheterization showed a possible "kink" in one of
his vessels and it was thought that he had a possible
"eddy" of current which led to a clot. He has been on
Coumadin since then as well as a calcium channel
blocker with the thought that there may have been a
superimposed spasm. He has had several unremarkable
stress tests since then. He works out on a Nordic-Track
three times a week without any chest pain or shortness
of breath. He has a history of possible peptic ulcer
disease in 1981. He was treated with H2 blockers and
his symptoms resolved. He has never had any bleeding
to his knowledge. He had a hernia repair bilaterally in
1989 and surgery for a right knee cyst in 1999, all of
which went well. He also has about a year long history of
right buttock pain. This happens only when he is sitting
for some time and does not change position. It does not
happen when he is walking or exercising. He wonders if
it might be pyriformis syndrome. If he changes positions
frequently or stretches his legs, this seems to help. He
has no acute complaints today and is here to get
plugged into the system. He does wonder if there is
anything else that can be done about his buttock pain.
PAST MEDICAL HISTORY: As above. In addition, he
had a flexible sigmoidoscopy in 2003 which was okay.
MEDICATIONS: Tylenol p.r.n., baby aspirin p.o. q.d.,
Coumadin 3.5 mg p.o. q.d., Adalat Time Released
tablets 30 mg one p.o. q.d., multivitamin, glucosamine
and chondroitin sulfate.
hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema. 2+
peripheral pulses.
NEUROLOGIC: Motor and sensation grossly intact.
PSYCHIATRIC: Normal affect and behavior.
DERMATOLOGIC: He has a small whitish papule at the
upper borderof his mustache on the left.
MUSCULOSKELETAL: Full range of motion of his legs
and hips bilaterally with no tenderness to palpation over
his buttocks.
ASSESSMENT/PLAN:
1. Status post myocardial infarction. No evidence for
actual CAD. He will continue his aspirin and
Coumadin. Unclear to exactly how long he should
be on Coumadin or if this is really needed. At
some point, may discuss this with cardiology. We
will check an INR today and get him plugged into
our Coumadin clinic. Check cholesterol.
2. High blood pressure. He will continue with diet
and exercise changes. At next visit, may go up on
his calcium channel blocker versus add another
agent. Check creatinine and potassium today.
3. Buttock pain. Will try some physical therapy.
4. Will send him to dermatology for the papule
above his mustache.
5. Possible h/o peptic ulcer disease. As he has not
had any known GI bleed, do not feel a need to
check H. pylori serology today.
6. Health maintenance. Tetanus shot today. Flex sig
as above. Will discuss prostate cancer screening
next visit.
7. Return to clinic in four months.
c
  
 

ALLERGIES: No Known Drug Allergies
FAMILY HISTORY: His mother had diabetes developed
at age 55 and coronary artery disease in her mid sixties.
His father had CAD as well but not until his 70s. A
paternal aunt had breast cancer. There is no history of
colon or prostate cancer.
SOCIAL HISTORY: He lives in Durham with his wife and
mother. He works for a biotech company. He does not
smoke. He drinks two beers per night and reports no
trouble with alcohol in the past. No history of drug use.
REVIEW OF SYSTEMS: As per his personal health
summary and is significant only for his buttock pain as
listed above, but is otherwise essentially unremarkable.
PHYSICAL EXAM:
VITAL SIGNS: Weight 175.2 pounds which is 79.3 kg,
blood pressure 142/96 by the nurse, 140/92 by me,
pulse is 64.
GENERAL: A healthy-appearing middle-aged
gentleman.
HEENT: Pupils equal, round, reactive to light.
Conjunctivaepink. Sclerae anicteric. Tympanic
membranes clear. Oropharynx clear.
NECK: No lymphadenopathy or thyromegaly or JVD.
LUNGS: Clear to auscultation and percussion.
HEART: Regular rate and rhythm without murmur, rub,
or gallop.
Richard L. Smith
1234567-8
4/5/2006
HISTORY OF PRESENT ILLNESS: Mr. Smith is a 63-
year-old gentleman new to our Clinic. He had been
followed by Dr. Jones at Kernodle Clinic. Mr. Smith has
a past medical history that includes hypertension for
more than five years. It sounds like he has fairly severe
white coat hypertension. Apparently, he has home
readings consistently 30 points below what he gets in
the office. He had been on Capoten in the past and
gotten a cough with that. He had been on Norvasc in the
past, but then stopped it for unclear reasons. More
recently, he has been on Hyzaar. He also has
hypercholesterolemia and has been on Lipitor. He has
for the past year or so felt that his hands and feet were
"burning up" at night. He reports that "he can almost see
the heat waves from them." He thinks this is a
medication side effect. On his own, he stopped his
Lipitor three weeks ago. He has not noticed any
difference in his symptoms. He otherwise feels well and
has no complaints.
PAST MEDICAL HISTORY: 1. Hypertension. 2.
Hypercholesterolemia. 3. Status post plastic surgery
after a motor vehicle collision when he was in his 20s. 4.
History of depression around the time of the accident.
He does report that intermittently he feels quite down,
but he is able "to pick himself back up". More recently,
however, he has been in a more prolonged period. 5. He
has significant moles and he is followed by an outside
dermatologist. 6. He has had normal PSA and rectal
exams. He had a colonoscopy about five years ago and
again one year ago, both of which showed many polyps,     

pathology not known. !   "

:
MEDICATIONS: Now only Hyzaar, a baby aspirin and a
multivitamin ¢ Hypertension, diagnosed ³years ago,´ well-
controlled with Metoprolol
ALLERGIES: Capoten caused a cough. ¢ Depression, poorly controlled; started Prozac 6
months ago but still feels depressed
SOCIAL HISTORY: He works in computer software. He
does not smoke. He drinks wine and Martinis "probably 
 # 
: MI, 2004
more than I need to." No drug use.
c$%
: Cardiac catheterization, post-
FAMILY HISTORY: The patient's father died of a brain MI, 2004
aneurysm in his 50s. Mom had colon cancer in her 80s
and also hypertension. Five older sisters all with  

hypertension and hypercholesterolemia. No known Aspirin 81mg po qd since his MI 3 years ago
coronary artery disease.
Metoprolol 100mg po qd ³for years´
REVIEW OF SYSTEMS:
Prozac 20mg po qd; Started 6 months ago
CONSTITUTIONAL: No fevers. Weight up 15 lbs since
March. HEENT: Teeth doing okay. Does not feel Protonix discontinued 12-18 months ago
congested in his sinuses. CARDIOVASCULAR: No
chest pains, palpitations, PND, orthopnea or edema. &$: No Known Drug Allergies, no food or insect
RESPIRATORY: No shortness of breath. He does have allergies
a chronic intermittent cough that he has had for years.
He had a chest x-ray a couple of years ago to evaluate '
this which was apparently normal. GI: No abdominal Mother died at age 74 of ³natural causes´; mother had
pain. No reflux-type symptoms. No change in bowel HTN ³for many years´
habits. GU: No hematuria or dysuria.
MUSCULOSKELETAL: No chronic joint pains. Father¶s medical history not known
PSYCHIATRIC: Not suicidal.
No known family history of colon cancer.
c
 
c
  : Mr. H
Mr. H is a retired factory worker. He is divorced and has

  
 : MD six children and one grandchild, whom he sees almost
daily. Despite this, Mr. H says he still often feels alone,

  
 
: October 1, 2007 isolated, and depressed. He denies past or present
tobacco and illicit drug use. He denies alcohol use. Mr. H
c
: The patient gives his own history and appears does not have health insurance but is now covered by
to be a reliable source. Medicare.


  : Abdominal pain (!c
:
â As indicated in the HPI, denies fevers or


 
chills; endorses decreased appetite and a 5lb weight
Mr. H is a 65 year old white male with a loss over the past 3-4 months; endorses fatigue
past medical history significant for an MI and depression
who presents today complaining of sharp, epigastric 
Y
abdominal pain of 3-4 months duration. The abdominal
pain has been gradually worsening over the past 3-4 ¢  â denies headache, dizziness, syncope
months. The pain has not changed or worsened acutely;
Mr. H seeks care for the pain at this time because he is ¢ â denies difficulty or changes in his hearing,
now covered by Medicare. The pain is located in the denies tinnitis
epigastric region and left upper quadrant of the
abdomen. It does not radiate. The pain is relatively ¢ 
â denies problems or changes in his vision;
constant throughout the day and night but does vary in denies blurred vision; denies seeing spots
severity. Mr. H rates the pain as 6/10 at its worst. Mr. H ¢  â Not assessed
describes the pain as a ³sharp, burning´ pain. He has not
tried taking any medicines to relieve the pain. The pain is ¢ â complains of a ³lump in his throat;´
not alleviated with rest. Mr. H thinks the pain may be endorses dysphagia
aggravated by throwing the football, but he has also â denies chest pain; denies palpitations
experienced the pain independent of playing football or
exerting himself. The pain is not associated with food or 

â denies shortness of breath, denies cough
eating, although Mr. H does endorse occasional
heartburn. Mr. H thinks the pain may at times be worse :
 
â As indicated in the HPI,
on laying down, and it does wake him up at night. Mr. H complains of sharp, epigastric abdominal pain; endorses
denies any abdominal trauma or injury. He endorses a constipation, denies diarrhea; endorses bloody stools
5lb weight loss over the past 3-4 months, decreased
appetite, and fatigue. He has experienced some :


â denies dysuria; denies increased
drenching night sweats, requiring him to change his shirt frequency or urgency of urination
but not his sheets. He describes a ³lump in his throat´
with associated dysphagia. He has experienced some  â denies numbness and tingling; denies
nausea with the abdominal pain but has not vomited. He paresthesias
endorses constipation. He endorses bloody stools with
some bowel movements. The blood is dark red in color
and is not bright red. There is a sufficient
amount of blood to turn the toilet water red. Mr. H does
not know how many times per week he experiences this
bleeding. He has not seen a bloody bowel movement in
the past week.
  â endorses abdominal pain occasionally
after throwing the football; denies any muscle or joint
pain


â not assessed
  â denies easy bruising
 )*
 by tumor. Therefore, based on this clinical presentation
„
: Ht 5¶10´ Wt 160lbs HR 72 RR 16 BP 126/78 and the life-saving importance of early detection, Mr. H
Temp Not measured should first be evaluated for colon cancer by
colonoscopy.
:
: Mr. H is a depressed-appearing white male in Gastric and duodenal ulcers can also cause epigastric
no acute distress. abdominal pain and bloody stools, secondary to gastric
bleeding. ³The symptoms of gastric and duodenal ulcers
 : Not examined are similar«[both are] characterized by epigastric pain 1
to 3 hours after a meal, or that awakens the patient at


 : Non-tender, no palpable masses night´ (Ruben, 567). Heartburn, nausea, and weight loss
can also occur with gastric and duodenal ulcers.
 : No masses Although Mr. H does not associate his abdominal pain
with food or meals, his pain does wake him up at night.
: Regular rate and rhythm; normal S1, S2; Furthermore, Mr. H¶s abdominal pain onset 2 months
no murmurs, rubs, or gallops after discontinuing Protonix, and he has experienced
heartburn, nausea, bloody stools, and weight loss,

: Lungs clear to auscultation bilaterally; No all of which can be associated with gastric and duodenal
wheezes or crackles ulcers. Therefore, gastric and duodenal ulcers should be
considered next in the differential (Ruben, 567-568)

:
Gastroesophageal reflux disease (GERD) can also
¢ Abdomen soft and non-distended with no scars or cause epigastric abdominal pain. Based on the
striations onset of Mr. H¶s abdominal pain 2 months after
discontinuing Protonix, and his symptoms ofa lump in his
¢ No pulsatile masses, no abdominal bruits throat, dysphagia, heartburn, and nausea, GERD should
ascultated be considered next in the differential (Ruben, 553-555).
¢ Spleen not palpable, liver not palpable Restarting Protonix therapy will decrease the
¢ Tender to palpation in epigastric region and amount of acid produced in Mr. H¶s stomach and should
left upper quadrant; No reflex tenderness; No alleviate symptoms resulting from gastric and duodenal
guarding; Murphy¶s sign negative ulcers and GERD. Therefore, if Mr. H¶s abdominal pain
is relieved with Protonix therapy, it can be attributed to
O : Hemoccult positive one of these gastric-acid based conditions.

:

 : Not examined Finally, intestinal obstruction secondary to chronic

constipation should be considered as a possible
 : Not examined contributing factor to Mr. H¶s abdominal pain. While such
an obstruction could explain Mr. H¶s pain, it does not
  : Not examined explain his worrisome symptoms of bloody stools or the
finding ofhemoccult positive stool and should therefore
s    : None collected be considered in addition to another, more complete,
explanation.
 $  + : Hemoccult positive stool
Similarly, anxiety or depression related abdominal pain,
 
s 
abdominal aortic aneurysm, pancreatitis, and pancreatic
cancer would not explain Mr. H¶s bleeding and, like
1. Abdominal pain, bloody stools intestinal obstruction, should only be considered in
2. Depression addition to another, more complete, explanation.

3. Hypertension  $   : Colonoscopy to evaluate the colon for

 
: Abdominal pain, bloody stools presence of polyps or tumors

    $ : colorectal adenocarcinoma, +   :

gastric ulcer, duodenal ulcer, GERD, intestinal
obstruction, anxiety or depression related, abdominal ¢ If colon cancer is detected on colonoscopy, refer
aortic aneurysm, pancreatitis, pancreatic cancer Mr. H to a GI oncologist.

 : ¢ Restart Protonix therapy

¢ Treat constipation with laxative as needed or daily
Given Mr. H¶s age, history of bloody stools, hemoccult Metamucil
positive stools on exam today, and the gravity of missing
a cancer diagnosis, colorectal adenocarcinoma should    )  : The importance of colonoscopy
be considered first in the differential. ³Increasing age is screening for colon cancer was discussed with the
probably the single most important risk factor for patient.
colorectal cancer in the general population. [Risk]
increases steadily to age 50, after which it doubles with  
: Depression
each decade´ (Ruben, 608). Colon cancer is usually
+    : Continue Prozac 20mg po qd for
initially clinically silent and most commonly presents as
hemoccult positive stools. However, large tumors can now. Consider switching to a different anti-depressant.
cause intestinal obstruction and associated constipation Discuss counseling and therapy options.
and abdominal pain. ³A positive test result for fecal  
,: Hypertension
occult blood predicts the presence of a cancer or an
adenoma in 50% of cases´ (Ruben, 609). ³Colon cancer +   : Continue metoprolol 100mg po qd
is the second leading cause of cancer-related death in
the United States´ (American Cancer Society). However,      : The importance of dietary salt and
if detected early and at a low stage, surgery can be fat restriction and exercise were discussed with the
curative. patient.
Thus, at age 65, Mr. H is at risk for colorectal cancer. c 
Furthermore, Mr. H¶s bloody stools, hemoccult positive
Rubin, R. and Strayer, D. Rubin¶s Pathology. 5th edition.
stool, weight loss, constipation, and abdominal pain are
Lippincott Williams and Wilkins, 2008.
worrisome for cancer and possible intestinal obstruction